LAUSR

A 41-year-old man with a benign bile duct stricture was initially evaluated at our institution for endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent exchange following plastic stent placement at an outside facility 2 months previously. His past medical history was notable for a motor vehicle accident resulting in abdominal crush injury and portal vein thrombosis. He then developed portal hypertension complicated by bleeding esophageal and gastric varices managed by splenectomy, with the creation of a mesocaval shunt. Due to subsequent stenosis of the mesocaval shunt, he underwent portal vein thrombectomy and remained on warfarin therapy. He additionally developed portal biliopathy with a distal common bile duct stricture managed by stent placement. Vital signs at the time of his procedure were notable for a heart rate of 82 beats/min, temperature of 37.2 C, blood pressure of 101/72 mm of Hg, and respiratory rate of 11/min. Physical examination revealed healed incisions consistent with his surgical history and mild right upper quadrant abdominal tenderness. His laboratory studies, including liver function tests, were unremarkable. At ERCP, the patient’s ampulla was located in a poorly accessible portion in the distal second part of the duodenum. There was no evidence of a biliary stent protruding into the ampulla. Fluoroscopy located a stent in the right upper quadrant consistent with proximal migration of the stent into the bile duct (Fig. 1). Several standard techniques typically utilized for the retrieval of proximally migrated stents were sequentially employed preceded by extending the existing sphincterotomy. Multiple attempts to grasp the stent with rat-tooth forceps (miniand full-sized) under fluoroscopic guidance were unsuccessful. Efforts at capture with a polypectomy snare, a basket, and a stone extraction balloon also failed. Attempts to cannulate and retrieve the stent using Soehendra stent extractors were similarly unsuccessful. Due to the length of the procedure, a decision was made to terminate with a plan to attempt cholangioscopy-assisted stent retrieval at a follow-up ERCP. An 8.5-Fr plastic stent was then placed alongside the proximally migrated stent. At the time of repeat ERCP for stent exchange 11 weeks later, the most recently placed stent was removed and the proximally migrated stent was still evident on fluoroscopy. A Spyglass cholangioscope (Boston Scientific, Marlborough, MA, USA) was advanced into the bile duct; the migrated stent’s distal end was embedded in the lateral wall of the distal bile duct with the proximal end impacted at the bile duct bifurcation, complicating attempts to directly cannulate the stent. The distal flange of the stent was grasped with a Spybite forceps, but due to the low closure force inherent with mini-forceps, the device slid off with each attempt to dislodge the embedded stent (Fig. 2a). A 0.03500 guidewire was then advanced through the cholangioscope into the stent’s flange side hole and through the stent under visual and fluoroscopic guidance. A 4 mm 9 2 cm biliary stone extraction balloon was advanced into the stent through the side flange, inflated, and then used to push and dislodge the embedded distal tip of the stent. Once the stent was floating freely in the bile duct, the cholangioscope was used to direct the 0.03500 guidewire into the stent through its distal tip (Fig. 2). The & Subhas Banerjee [email protected]